Fluids and Electrolytes

Fluid and Electrolytes

Fluid and Electrolytes

Fluids Solvent Solute Solution

Body Fluids

I. water
a. the most important nutrient of life

primary function of water in the body

provides a medium for transport facilitates cellular metabolism

 acts as a solvent helps maintain normal body temperature facilitates digestion and promotes elimination Lubricant Insulator

Water overview
*Water comprises about 50% -70% of the total body weight *Varies with age weight gender

Normal Composition in Average Man

When a person loses more than 10% of his total body fluids,he can DIE!!!

Body Fluids Compartment

I. intracellular fluid (ICF) compartment a. contains fluid within the cells

Potassium (K+): most prevalent intracellular cation

Phosphate (PO4-): most prevalent intracellular anion

Body Fluids Compartment

II. extracellular fluid (ECF) compartment a. contains fluid outside the cells includes: i. intravascular fluid ii. interstitial fluid

Body Fluids Compartment

Interstitial
(Cl-): most prevalent anion (Na+):most prevalent cation

Intravascular (IV)
Within vascular space

III. Transcellular Fluid

Small but important fluid compartment

Body Fluids Compartment

III. total-body water

in the normal adult, total-body water: i. represents 50% - 70% of the body weight of a normal adult ii. total-body water is divided as follows: a. cell fluids b. ECF c. plasma d. interstitial fluid

Body Water 50-70% of body weight is Water

Intracellular (ICF) Fluid located within cells Most stable, fairly resistant to major fluid shifts Extracellular (ECF) Consists of interstitial fluid, plasma, and transcellular water

TOTAL BODY FLUID (70 KG.) = 40 LITERS

CELL FLUID 25 LITERS EXTRACELLULAR FLUID 15 LITERS
PLASMA 3 LITERS INTERSTITIAL & TRANSCELLULAR 12 LITERS

Distribution of Body Solids & Fluids

Body Fluid Compartments

Intracellular Within Cells
55% or 2/3 TBW

Extracellular Outside cells

42.5% or 1/3 TBW

Transcellular Contained in body cavities

2.5%

Potassium* Phosphates Magnesium

Sodium* Bicarbonates Chloride

CSF, Pleural fluid, Synovial Fluid and peritoneal fluid Secreted by epithelial cells Bound

Interstitial Fluid surrounding the cells 20%TBW or 2/3 of ECF

Intravascular Within the blood vessels

1/3 of ECF Plasma Bone and 7.5% Cartilage 7.5% Higher protein Dense content Connective tissues 7.5%

Variations in fluid content

a. a person's age a. infants have considerably more body fluid and ECF than adults b. lean body mass i. fat cells a. contain little water ii. lean tissue a. is rich in water c. gender FEMALES VS. MALES

Total Body Water

Total body water = 0.6 X weight (kg) for children and adults and 0.78 X weight (kg) for neonates and infants

Tonicity of Body Fluids

A. isotonic solutions - have the same osmolality as body fluids B. Hypotonic- have a lesser or lowers solute concentration than plasma hypotonic solutions - have a lower osmolality than body fluids C. Hypertonic- higher or greater concentration of solutes hypertonic solutions - have a higher osmolality than body fluids

Electrolytes
I. substances capable of breaking down into electrically charged ions when dissolved in solution II. ion a. atom or molecule carrying an electrical charge b. types of ions i. cations ii. Anions

Normal Composition in Average Man

Plasma/ Intravascular Cations (mmol per litre) Sodium Potassium Calcium Magnesium Anions (mmol per litre) Chloride Bicarbonate Phosphate Sulphate Protein Organic Anions 102 27 1 0.5 2 3 114 30 1 0.5 0.1 6 5 10 50 10 8 2 140 4 2.5 1 144 4 2 1 10 155 1 15 Interstitial Fluid Intracellular fluid

Major Electrolytes
Sodium Potassium Calcium Magnesium Chloride Bicarbonate Phosphate

Non-electrolytes
substances incapable of breaking down into electrically charged ions when dissolved in solution and, consequently, remain intact

Measurement of Electrolytes
measured in terms of their chemical combining power, or chemical activity unit of measurement of electrolytes i. the milliequivalent (mEq) - describes the chemical activity of electrolytes

Fluid Exchange Processes

- movement of water and electrolytes between fluid compartments takes place by a variety of processes

Fluid Intake

Healthy adult ingests fluid as part of the dietary intake. 90% of intake is from the ingested food and water 10% of intake results from the products of cellular metabolism

Fluid Output The average fluid losses amounts to 2, 500 ml per day, counterbalancing the input.

The routes of fluid output are the following: SENSIBLE LOSS INSENSIBLE LOSS

Water Metabolism
Daily Balance: turnover ~ 2500 ml

a. Intake
i. drink ~ 1500 ml ii. food ~ 700 ml iii. metabolism ~ 300 ml

b. Losses
i. urine ~ 1500 ml ii. skin ~ 500 ml
insensible losses ~ 400 ml sweat ~ 100 ml
iii. lungs ~

400 ml iv. faeces ~ 100 ml

Water Loss ROUTES OF WATER LOSS

-SENSIBLE Urine Feces -INSENSIBLE Lungs Sweat

Causes of Increased Water Loss

Fever Diarrhea Diaphoresis Vomiting Gastric suctioning Tachypnea

Causes of Increased Water Gain

Increased sodium intake Increased sodium retention Excessive intake of water Excess secretion of ADH

Fluid Spacing

First spacing Second spacing Third spacing

Fluid Imbalances

FLUID VOLUME DEFICIT or HYPOVOLEMIA

This is the loss of extra cellular fluid volume that exceeds the intake of fluid. The loss of water and electrolyte is in equal proportion. It can be called in various terms- vascular, cellular or intracellular dehydration. But the preferred term is hypovolemia.

Nursing Process in Fluid Volume Deficit

ASSESSMENT: Physical Examination
Weight loss, tented skin turgor, dry mucus membrane Hypotension Tachycardia Cool skin, acute weight loss Flat neck veins Decreased CVP

Nursing Process in Fluid Volume Deficit

NURSING MANAGEMENT
1. Assessment 2. Monitor daily weights 3. Monitor Vital signs, skin and tongue turgor, urinary concentration, mental function and peripheral circulation 4. Prevent and Correct Fluid Volume Deficit

5. Maintain skin integrity 6. Provide frequent oral care 7. Teach patient to change position slowly to avoid sudden postural hypotension

FLUID VOLUME EXCESS: HYPERVOLEMIA

Refers to the isotonic expansion of the ECF caused by the abnormal retention of water and sodium There is excessive retention of water and electrolytes in equal proportion.

Nursing Process in Fluid Volume Excess

ASSESSMENT Physical Examination
Increased weight gain Increased urine output Moist crackles in the lungs Increased CVP Distended neck veins Wheezing Dependent edema

Nursing Process in Fluid Volume Excess

NURSING MANAGEMENT
Continually assess the patients condition Prevent Fluid Volume Excess Detect and Control Fluid Volume Excess Teach patient about edema, ascites, and fluid therapy. Instruct patient to avoid over-the-counter medications without first checking with the health care provider

Electrolyte Imbalances

Electrolytes Sodium (Na+)

chief electrolyte in the ECF average daily requirement: a. average daily requirement i. not known sodium-rich foods: a. bacon b. mustard c. processed cheese d. canned vegetables e. salted snack foods

Electrolytes Sodium (Na+)

losses: a. eliminated primarily by the kidneys

normal range for serum sodium???

HYPERNATREMIA
sodium excess in the ECF

Nursing Process in HYPERNATREMIA

Clinical Manifestations
primarily neurologic. Hypernatremia results in a relatively concentrated ECF, causing water to be pulled from the cells. If hypernatremia is severe, permanent brain damage can occur (especially in children).

Nursing Process in HYPERNATREMIA

ASSESSMENT Physical Examination
Restlessness, elevated body temperature Disorientation Dry, swollen tongue and sticky mucous membrane, tented skin turgor Flushed skin Increased muscle tone and deep reflexes Peripheral and pulmonary edema

Nursing Process in HYPERNATREMIA

NURSING MANAGEMENT
Continuously monitor the patient Prevent hypernatremia Monitor serum sodium level. Reposition client regularly Provide teaching to avoid over-the counter medications without consultation as they may contain sodium

HYPONATREMIA
Refers to a Sodium serum level of less than 135 mEq/L. This may result from excessive sodium loss or excessive water gain.

Nursing Process in HYPONATREMIA

Clinical manifestations of hyponatremia depend on the cause, magnitude, and rapidity of onset. Physical Examination
Altered mental status Vomiting Lethargy Muscle twitching and convulsions (if sodium level is below 115 mEq/L) Focal weakness

Nursing Process in HYPONATREMIA

NURSING MANAGEMENT
Provide continuous assessment Maintain seizure precaution Detect and control Hyponatremia

Electrolytes Potassium (K+)

chief electrolyte in the ICF average daily requirement: b. intake of 50 - 100 mEq maintains K+ balance potassium rich foods: a. bananas b. oranges c. prunes d. broccoli e. potatoes

Electrolytes Potassium (K+)

losses: a. excreted primarily by the kidneys b. gastrointestinal excretions c. some perspiration and saliva normal range for serum potassium???

HYPOKALEMIA
potassium deficit in the ECF, or serum potassium level less than 3.5 mEq/L

Nursing Process in Hypokalemia

Clinical Manifestations
Potassium deficiency can result in widespread derangements in physiologic functions and especially nerve conduction. Clinical signs rarely develop before the serum potassium level has fallen below 3 mEq/L unless the rate of fall has been rapid.

Nursing Process in Hypokalemia

Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, decreased bowel motility, paresthesias, dysrhythmias, and increased sensitivity to digitalis. If prolonged, hypokalemia can lead to impaired renal concentrating ability

Nursing Process in Hypokalemia

ASSESSMENT
Physical examination
Muscle weakness Decreased bowel motility and abdominal distention Paresthesias Dysrhythmias Increased sensitivity to digitalis

Nursing Process in Hypokalemia

ASSIST IN THE MEDICAL INTERVENTION
Provide oral or IV replacement of potassium

NURSING MANAGEMENT
Continuously monitor the patient Prevent hypokalemia Correct hypokalemia by administering prescribed IV potassium replacement.

Administer IV potassium no faster than 20 mEq/hour and hook the patient on a cardiac monitor. A concentration greater than 60 mEq/L is not advisable for peripheral veins.

HYPERKALEMIA
potassium excess in the ECF, or serum potassium level greater than 5.0 mEq/L

Nursing Process in Hyperkalemia

Clinical Manifestations
By far the most clinically important effect of hyperkalemia is its effect on the myocardium. Cardiac effects of an elevated serum potassium level are usually not significant below a concentration of 7 mEq/L (SI: 7 mmol/L) As the plasma potassium concentration is increased, disturbances in cardiac conduction occur.

Nursing Process in Hyperkalemia

ASSESSMENT
Physical Examination
Diarrhea Skeletal muscle weakness Abnormal cardiac rate

Nursing Process in Hyperkalemia

IMPLEMENTATION
ASSIST IN MEDICAL INTERVENTION Monitor the patients cardiac status with cardiac machine Institute emergency therapy to lower potassium level by:
Administering IV calcium gluconate Administering Insulin with dextrose Administering sodium bicarbonate Administering Kayexalate (cation-exchange resin)

Nursing Process in Hyperkalemia

NURSING MANAGEMENT
Provide continuous monitoring Assess for signs of muscular weakness, paresthesias, nausea Evaluate and verify all HIGH serum K levels Prevent hyperkalemia Correct hyperkalemia by administering carefully prescribed drugs. Assist in hemodialysis if hyperkalemia cannot be corrected. Provide client teaching. Monitor patients for hypokalemia who are receiving potassium-sparing diuretic

Electrolytes Calcium (Ca++)

most abundant electrolyte in the human body a. 99% is in the bones and 1% is in the ECF a. average daily requirement i. 1 g for adults

Electrolytes Calcium (Ca++)

calcium rich foods: losses: a. milk a. urine, feces, bile, digestive b. cheese secretions, c. calcium-fortified perspiration tofu normal range for d. almonds serum calcium???

HYPOCALCEMIA
calcium deficit in the ECF, or serum calcium level less than 8.5 mEq/L

HYPOCALCEMIA
signs/symptoms
mental changes convulsions spasm of larygneal muscles ECG changes Management Dependent on the presenting SSx Administration of medications such as Calcium Gluconate (IV) Calcium Chloride if severe Calcium carbonate

HYPERCALCEMIA
calcium excess in the ECF, or serum calcium level greater than 10.5 mEg/L

HYPERCALCEMIA
signs/symptoms
muscular weakness constipation anorexia, nausea, vomiting decreased memory and attention span polyuria and polydipsia renal stones neurotic behavior cardiac arrest

HYPERCALCEMIA

The need for treatment of hypercalcemia depends on the degree of hypercalcemia and the presence or absence of clinical symptoms.

Electrolytes Magnesium
second most important cation in the ICF a. primarily found in the ICF

average daily requirement:

i. 18 - 30 mEq for adults ii. higher amounts are required for: a. children

magnesium rich foods: a. vegetables b. nuts c. fish

Electrolytes Magnesium
losses: a. excreted by the kidneys normal range for serum magnesium: a. 1.3 - 2.1 mEg/L (mmol/L) with 1/3 of that bound to plasma proteins

HYPOMAGNESEMIA
magnesium deficit in the ECF, or serum magnesium level less than 1.3 mEg/L

HYPOMAGNESEMIA
signs/symptoms
neuromuscular irritability increased reflexes coarse tremors convulsions cardiac manifestations tachyarrythmias increases susceptibility for digitalis toxicity mental changes disorientation mood changes

HYPOMAGNESEMIA
Management

Treatment of hypomagnesemia depends on the degree of deficiency and the clinical effects.

HYPERMAGNESEMIA
magnesium excess in the ECF, or serum magnesium level greater than 3.0 mEg/L

HYPERMAGNESEMIA
signs/symptoms
flushing a sense of skin warmth hypotension depressed respirations drowsiness, hypoactive reflexes, and muscular weakness cardiac abnormalities

Management
Dialysis Cardiotoxicity Management Calcium Gluconate 10% 1-10 ml IV

Electrolytes Phosphate (PO4-)

chief anion in the ICF a. present also in the ECF, bone, skeletal muscle, and nerve tissue average daily requirement: a. 1 g for adults b. higher amounts are required for: i. children ii. pregnant and lactating women iii. post-menopausal women not taking estrogen iv. people over 65 phosphate rich foods

Electrolytes Phosphate (PO4-)

losses: a. excreted by the kidneys

normal range for serum phosphate: 2.5 - 4.5 mEg/L (mmol/L)

HYPOPHOSPHATEMIA
phosphate deficit in the ECF, or serum phosphate level less than 2.5 mEg/L
signs/symptoms
cardiomyopathy acute respiratory failure seizures decreased tissue oxygenation joint stiffness

HYPOPHOSPHATEMIA
Standard intravenous preparations of potassium phosphate are available and are routinely used in malnourished patients and alcoholics. Oral supplementation also is useful where no intravenous treatment is available. Historically one of the first demonstrations of this was in concentration camp victims who died soon after being refed: it was observed that those given milk (high in phosphate) had a higher survival rate than those who did not get milk.

HYPERPHOSPHATEMIA
phosphate excess in the ECF, or serum phosphate level greater than 4.5 mEg/L
signs/symptoms
symptoms of tetany, tingling of the fingertips and around the mouth numbness muscle spasms

HYPERPHOSPHATEMIA
Management
High phosphate levels can be avoided with phosphate binders and dietary restriction of phosphate.

Electrolytes Chloride (CL-)

chief electrolyte in the ECF a. present in the blood, interstitial fluid, lymph, and in minute amounts in the ICF

chloride rich foods: a. foods high iN sodium b. dairy products c. meat

Electrolytes Chloride (CL-)

losses: a. excreted by the kidneys normal range for serum chloride: a. 95 - 105 mEg/L (mmol/L)

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